Indian Country COVID-19 teleECHO Clinic Sign-In

Thank you for attending today's Indian Country COVID-19 teleECHO session. The 1 hour long session includes an opportunity to engage in didactic sessions focused on COVID-19 clinical care, facility readiness, and emergent issues as they come up.

Please complete the sign-in information below for today's clinic attendance.

Question Title

* 1. Please choose the date of the COVID-19 ECHO Clinic you are attending:

Date of Clinic

Date

Question Title

* 2. Please Enter Your Contact Information. (If you would like a copy of the clinic's slides, please include a valid email address.)

First Name

Last Name

Tribe/Tribal Organization/Clinic Name

City/Town

US State/Territory

Canadian Province (If applicable)

Email Address

Question Title

* 3. What is your professional licensure?

DMD/DDS

Pharmacist

Behavioral Health

Other (please specify)

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* 4. Please select which IHS Service Area your tribe/ tribal organization/ clinic is located in?

Alaska

Albuquerque

Bemidji

Billings

California

Great Plains

Nashville

Navajo

Oklahoma City

Phoenix

Portland

Tucson

Not applicable

Question Title

* 1. Please choose the date of the COVID-19 ECHO Clinic you are attending:

Question Title

* 2. Please Enter Your Contact Information. (If you would like a copy of the clinic's slides, please include a valid email address.)

Question Title

* 3. What is your professional licensure?

Question Title

* 4. Please select which IHS Service Area your tribe/ tribal organization/ clinic is located in?

Question Title

* 5. What question(s) do you have relating to COVID-19? Our faculty will respond directly if an email is listed above.